Although we like to talk around here about exciting topics like shock and airway management, the reality is that for many EMS providers — particularly at the BLS level — a large part of this job isn’t stabilizing emergencies. It’s routine work like dialysis trips and stable transfers from nursing facilities. Some folks find this stuff dull, and it can be dull, but the best way to make it interesting is to approach it just like the exciting stuff and try to be excellent at both aspects of the job.

How can you excel at bringing Mr. Smith to his third doctor’s appointment this week? You can learn to be a really good patient advocate on his behalf, something that almost all residents of long-term care facilities need. We’re well-positioned to fill this role because we have a one-on-one relationship with our patients. Unfortunately, we often lack the know-how and leverage to resolve most of their problems.

Our feature in the August 2014 issue of EMS World talks about how to use the ubiquitous Long-Term Care Ombudsman program to help. It’s easy, it works, and even if you didn’t know about it, there’s one available in your area. Give it a read and think about bringing it to bear the next time the guy on your stretcher has something to say!

“Hi, my name is Brandon. I’m an EMT with Save-a-life Ambulance. Can I help you?”

Anybody remember that? I think it was on page 6 of the EMT textbook.

I suppose it’s about communicating your name, which is nice. And it’s about obtaining consent, which is important, although in reality, consent in EMS is usually handled the same way as consent in sexual activity — you just go until someone says stop.

But mainly it’s about courtesy and professionalism. It’s gauche to swoop into a room and just start playing with somebody’s lesions without so much as a how-do-you-do.

The trouble is that the formal intro is so hokey nobody actually uses it. Or uses anything remotely similar. And I think that’s a shame, because although it’s silly, it’s getting at something important.

We understand that people call us mainly to bring some order to their crisis. Obviously, that involves Doing Medicine. But the medicine is just a means to an end.

Why do we call plumbers? When your sink starts flooding water into the kitchen, you don’t know what to do. This situation is alien; it’s outside of your expertise. You may be very good at many things in life, such as fueling your car, tying your shoes, and making cherries jubilee, but you don’t know what to do about this.

You know that there are people who have the answers, though; they’re called plumbers. So you call a plumber, and say, make it right.

We’re the same way. People don’t know what to do when they get chest pain or crash their car. But they know that if they call 911, professionals will come who know what to do. So they call us. That’s why people sometimes ask 911 to fetch cats out of trees or ask when the circus is coming to town. It’s why the first reaction of so many motorists after a crash is to call their spouse or their dad.

The thing is, when we walk in and our first reaction is to Do Medicine, it’s not helping the problem. All that medicine is just more strangeness, unless your patient is a fellow clinician. So now their distress is going to continue until you can finally tell them what’s wrong. Except you won’t, because you don’t think you’re qualified for that. So now they’ll stay confused and scared until they get to the hospital. And on and on.

Throw them a rope!

The fastest way to restore normality to a situation is to reintroduce a familiar activity. And social courtesies are very familiar to everyone.

When you introduce yourself and shake someone’s hand, they’re transported from the confusing world of a medical crisis to something much more comfortable. They know how to do this. Smile, shake, say your name. It’s easy. They’re good at it.

Sometimes patients are visibly shocked when you do this, and seem to reset; you can literally watch them change channels. Now they’re a little calmer, a little happier, and you can work with that. With enough balls, you can pull this off in the most outrageous circumstances. Sing praise for the EMT who can walk in on the triple traumatic amputation and say “Hi! I’m Jim. What’s going on?”

Now, of course, you don’t want to minimize the patient’s distress. In an emergent situation, it can be galling and obnoxious for their freak-out to be met by your apparent apathy or boredom. That’s why you have to find a middle ground between projecting calm confidence and acknowledging the seriousness (perceived or real) of the patient’s situation. Don’t let them drag you along into panic, but don’t try to abruptly pull them to a halt either; strike a balance, pace them, and then gradually slow them back down. The point is that introducing yourself like a regular person is a powerful tool for restoring normality to a crazy situation: use that tool liberally, but intelligently.

I’ve had patients tell me I was the only Medical Person they could remember introducing themselves. That’s a damned shame. People greet each other and make a introduction when they meet. And aren’t patients people?

It was around 11:00 AM when we were called to a local skilled nursing facility for a hip fracture. The patient was a 61-year-old male with mild mental retardation and several other issues, who’d fallen last night while walking to the bathroom. He was helped back to bed with moderate hip pain, and the staff physician stopped by to check him out. A portable X-ray was performed, which the physician interpreted as showing a proximal femur fracture as well as an associated pelvic fracture. This was communicated to us via a scrawled note and a cursory report.

The patient was found resting comfortably in bed, semi-Fowler’s and alert. He had no complaints at rest, although his pelvis and left femoral region were mildly tender and quite painful upon movement. No deformity was notable and there was no obvious instability. His vitals were stable and he was generally well-appearing, in no apparent distress. He denied bumping his head and had no pain or tenderness in the head or neck.

We gently insinuated a scoop stretcher underneath him, filled the nearby voids with towels and other linen, and bundled him into a snug, easily-movable package. Then we gave him the slow ride to his requested emergency department, a teaching hospital in town just a few minutes away.

We rolled into the ED and were lifting him into bed on the scoop when a young man entered the room, bescrubbed and serious-looking. I gave a brief report. As the words “pelvic fracture” left my lips, his mental alarms started visibly beeping and flashing, and he hurriedly asked, “What kind of pelvic fracture?”

“Okay, but pelvic fractures can be a big deal. It could be … ” he sucked in air, “… open-book. There could be a lot of bleeding.”

I stared at him. “Well, sure. But he’s been stable since last night, and has a basically normal physical with no complaints at rest. He’s not exactly circling the drain.”

He didn’t seem to hear me as he briskly approached the patient and began poking him and asking questions. While we pulled our stretcher out of the room, he asked, “Does your neck hurt at all?”

Now that the patient had been stuck on a scoop stretcher for over twenty minutes, he thought for a moment and then shrugged. “Sure.” The doctor immediately ordered the placement of a cervical collar.

As we escaped, he was on the phone to the SNF, and the last thing I heard was him berating them with his urgent need to know exactly what type of pelvic calamity the patient had suffered.

What was the failure here? It was a failure of clinical judgment.

Clinical judgment is a phrase which means different things to different people, and often its meaning is so nebulous (much like “patient advocacy“) that it sounds good while saying nothing. But most would agree that it means something like this: the ability to combine textbook knowledge and personal experience, applying them intelligently to the current patient’s situation to yield an accurate sense of the possible diagnoses and the costs vs. benefits of possible treatments. In other words, it means knowing what the patient’s probably got and what to do about it, which is the heart of medicine anyway. So what’s all the fuss about?

In reality, when clinical judgment is mentioned, what’s often meant is something specific: the wisdom to know when something’s not wrong. Much of medicine is about planning for the worst, ruling out the badness, and looking for the unlikely-but-possible occult killer that nobody wants to miss. As a result, we often act as if nearly everybody is seriously ill, even when they probably aren’t.

On a practical level, most complaints — from chest pain to the itchy toe — could conceivably represent a disaster. Anything’s possible. So if we want to truly adopt perfectly mindless caution, we should be intubating every patient and admitting them directly to the ICU so that we’re ready when their skin melts off and their eyes turn backwards.

But we can’t do that, and we shouldn’t. So how do we know when to do a little less? Clinical judgment.

Clinical judgment is the acumen to assess a patient and say, “I think we’re okay here. Let’s hold off on that.” It’s what you develop when you have both the knowledge and experience to understand that a person is low-risk, and that certain tests or treatments are more likely to harm than to hurt them. That doesn’t mean that nothing will be done, or that more definitive rule-out tests will not occur, but it means you’re not freaking out in the meanwhile. It’s a triage thing.

Put another way, imagine the patient who you’re placing in spinal immobilization, or providing with supplemental oxygen, or to whom you’re securing a splint. They ask, “Look, I don’t much like this; do I really need it?” Well, I don’t know, rockstar — does he? If you’re simply acting on algorithms, reflexively doing x because you found y, then you really don’t know. How important is that oxygen? To answer that, you’d need to truly understand the benefits versus the potential harms, which means having a strong grasp of the mechanism of action, familiarity with the relevant literature (including the pertinent odds ratios, NNT and so forth), prior experience with similar patients, et cetera… only with that kind of knowledge do you really understand what’s happening. In essence, the patient is asking for the informed element of informed consent, something he’s entitled to, and you can’t provide it if you don’t have it yourself.

But when you do develop that depth and breadth of knowledge, you gain a special ability. It’s the ability to do less. When you truly understand what you’re dealing with, and more importantly, what you’re not dealing with, you can titrate medicine to what’s actually needed and stop there. Along with the knowledge comes the confidence, because you don’t merely know, you know that you know; in other words, you don’t need to take precautionary steps merely because you’re worried there might be considerations you don’t understand.

When it comes to withholding anything, even the kitchen sink, you might ask, “isn’t there risk here?” And strictly speaking, there is risk. But you can set that bar wherever you want. The important thing to grasp is that “doing everything for everyone” is not the “safe” approach; overtriage and overtreatment are not benign. All those things you’re doing have a cost. They may cause real harm. Even at best, they cost time and money, and subject the patient to unnecessary discomfort and inconvenience. We’d like to minimize all that whenever possible.

So, we return to the gentleman with the pelvic fracture. Strictly speaking, fracture of the pelvis has the potential to be life-threatening; certain types of unstable fracture can cause massive bleeding, along with damage to nervous, urinary, and other structures. So a textbook response to “pelvic fracture?” might be to treat it as a high-risk trauma.

But a patient with an unstable, severely hemorrhaging open-book pelvic fracture probably wouldn’t look like that. It would be evident; it would cause a number of apparent effects, such as pain and distress, shock signs, altered vitals, deformity or palpable instability. Except in bizarre cases or in patients who are clinically difficult to evaluate, big problems create big changes. While it’s true that we don’t know exactly what the X-ray showed, so one could theoretically argue for any conceivable pathology, there’s no question that the patient appeared stable, had remained unchanged for many hours, and had apparently been judged low-acuity after evaluation and imaging by his own doctor. In other words, let’s take it easy.

The question of spinal immobilization is another example. Strictly speaking, could we rule out the possibility of a cervical spine fracture? Well, no. Not without CT and MRI and even then who knows. But the fall was many hours ago, the patient was freely mobile and turning his head throughout that period, had no peripheral neurological deficits, denied striking his head or loss of consciousness, and quite frankly, had no pain until he spent twenty minutes with his head against a metal board.

It’s not often that you find a doctor more concerned about C-spine than an EMT. How did it happen here?

Despite the fact that we delivered the patient to a major tertiary center, it was nevertheless a teaching hospital, and the new interns had just hit the wards. While this particular clinician was undoubtedly smart and well-educated, at this stage he had about two weeks of experience behind him, and that is not conducive to providing judicious (rather than applied-by-spatula) care. He had neither the experience to know when to take it easy, nor the confidence in that experience to stand by such a decision.

We don’t want to take this concept to its extreme, which would involve doing very little for most of our patients. In the end, this is still emergency medicine, and emergency care will always involve screening for the deadly needle in the benign haystack. There’s also danger in simply becoming lazy and burned-out, and using Procrustean application of cynical “street smarts” to justify never bothering with anything. The real goal is to do the right things for the right reasons, no more, no less. And to get to that point, you have to put in some time.

One more post about glucometry is pending, but for now, something lighter.

Decades of medical interns have been raised on the Laws of the House of God. The House of God was a cynical and dark look into the world of modern medicine, and its “Laws” were about as uplifting as condensed soup, but they rang true enough that you’ll still hear them quoted in the halls of medicine today (including those of the real-life “House of God,” where I find myself more shifts than not).

In any case, laws come in handy. Although I’m a believer in the nuanced and detailed analysis, as I age and my neurons gradually turn to cotton candy, I increasingly see the value in basic rules of thumb to guide us through the tangled web of life, and especially of this job.

A good law is simple. It’s always true, or almost always, and the exceptions prove the rule. It’s not specific to a certain region or company, but is something you can keep under your hat and carry with you throughout your career. It’s clear and it say something fundamental about the kind of provider you want to be. But most of all, a good law is not just an empty platitude, but rather an actionable guide-post that can answer real questions in real situations. When times are hard or temptations loom, it’ll tell you what to do.

With no further ado, then, here are mine. I believe in them, I follow them, and like good unguent, I wholeheartedly prescribe them for universal application. I am not wise, but whenever I do a good job of faking it, it’s by following these principles.

THE LAWS OF EMS

Help your patient in any way you can.

Be nice to everybody. It’s your job.

If you can’t save their life, make their day a little better.

Protect your partner.

Have a reason for everything you do.

Leave the patient better off than when they met you.

It should get calmer when you show up.

Good habits make doing the right thing easy.

Tomorrow, nothing will remain but your documentation.

Everything’s a bigger deal to the person on the stretcher.

But that’s just me. What laws do you believe in?

Editor’s note: this post was expanded into a feature piece for EMS World Magazine in the March 2014 issue.

Eventually, we all reach EMS satori — I’m referring, of course, to the realization that most of our job doesn’t involve saving lives, or performing any high-level, acute medical interventions. Once we understand this, the question becomes: what does our job consist of?

One good answer among many is the management of psychological rather than physical injury. Can we help the person, even when there’s little need to help the body? We sure can, and it seems like after all the hours we spent studying airway management, we should spend at least a little time developing this other skill. If we’re going to surrender our identity as ET tube samurai, we’d better become experts at dropping mental balms.

It may not be rocket science, but there is certainly a right and a wrong way to help. One good source of ideas for doing it the right way is called psychological first aid.

Psychological first aid, or PFA, is a system developed jointly by the National Child Traumatic Stress Network and the National Center for PTSD. It’s meant to be a psychological counterpart to medical first aid — not a replacement for long-term professional therapy, but merely a method for addressing the immediate, acute mental stress response following crisis. It’s largely aimed at post-disaster scenarios, such as the victims of hurricanes and mass casualty incidents, and it’s become the preferred methodology for American Red Cross personnel. However, it also has valuable concepts that we can use every day on the ambulance, to help us care for both patients and any of their family or friends who are struggling.

This sort of thing may come naturally to some people, but PFA rolls it together into a standalone curriculum that can be transmitted to any professional, particularly those of us who don’t specialize in mental health. It’s also evidence-based: there is research behind most of its interventions, and the science tells us that it generally works. (Contrast this to CISM, which many feel is baseless at best and counterproductive at worst.)

Classes are available; check with your local Red Cross for more information. But here are some of the concepts:

General ideas

Take your cues from the patient. If they want to talk, listen. If they don’t, don’t force them.

You’re here as support and to listen, not as Dear Abby; limit your input and resist the urge to offer advice. Be sparing with relating personal anecdotes or “war stories,” even if they seem germane; it’s the patient’s crisis, not yours.

Cater your approach to the patient’s age and culture. Children in particular will need a different style than adolescents and adults. When approaching children, make contact with parents first, and understand that both parties will probably need to be attended to.

Reassure them that their emotions and reactions, no matter what they may be, are understandable and acceptable, not pathological.

Understand your own role and limitations, and be ready to bring in better-trained specialists.

Avoid these types of remarks:

I know how you feel.

It was probably for the best.

She is better off now.

It was his time to go.

Let’s talk about something else.

You should work towards getting over this.

You are strong enough to deal with this.

You should be glad she passed quickly.

That which doesn’t kill us makes us stronger.

You’ll feel better soon.

You did everything you could.

You need to grieve.

You need to relax.

It’s good that you are alive.

It’s good that no one else died.

Major Goals

1. Contact and Engagement

As you go about the business of the call, make sure that you’re orienting yourself as somebody who’s willing and able to help. From the initial patient contact all the way until you shake hands and part ways, you should be presenting yourself as a compassionate professional; all it takes is one slip of the tongue or roll of the eyes to betray that you’d rather be back at quarters finishing your burrito.

2. Safety and Comfort

Obviously, you should ensure that you are both physically safe, and that immediate medical concerns are managed; this also includes the recognition of patients who could harm themselves or others (like you).

If you’re still at a scene or in the ED where upsetting things are happening (such as a resuscitation), try to move somewhere more quiet and controlled. Keep them physically comfortable, with blankets, a chair, food or water, etc. Remove them from anyone who is themselves panicked or emotionally distressed, but do help to put them in contact with social support, such as friends, family, or clergy.

Try to give people active, familiar things to do, rather than sitting there passively being overwhelmed. Anything, even minor tasks (“here, hold this”), that involve them with their own care or the care of their loved one is beneficial; perhaps they can make some phone calls or locate insurance information.

Share whatever information you have regarding what’s currently happening, including what’s happening to others affected, and what can be expected next (do use judgment on how much they want/need to hear at this stage, though). But don’t lie, guess, form unfounded predictions, or make promises beyond your control (“they’ll/you’ll be just fine”). Consider a broad interrogatory like “Is there anything else you’d like to know?”

Kids may appreciate something like a teddy bear, and you can use it as a proxy for their own care, for instance: “Remember that she needs to drink lots of water and eat three meals a day — and you can do that too.” Also, children especially are sensitive to alarming sights and sounds; try to shelter them from unnecessary stimuli.

3. Stabilization (if needed)

As we’ve talked about before, anyone experiencing an acute, uncontrolled emotional response needs to be stabilized and grounded before much else can be done. Be on the lookout for things like: glassy-eyed or vacant stares; aimless wandering or unresponsiveness; uncontrolled crying, hyperventilating, shaking, or rocking; or frantic, illogical, even potentially dangerous behavior such as perseverating on simple tasks (continuously searching for a pair of glasses) or walking thoughtlessly through traffic. Remember that reactions may ebb and flow in surges.

Rather than broad reassurances — “stay calm” — try to determine their specific concerns, even if not entirely rational, and help address them. If completely adrift, patients may be assisted in “grounding” by deep breathing and asking them to describe where they are or concrete aspects of their surroundings (I see a table, I see a clipboard).

Consider both giving them some brief privacy (do tell them when you’ll be back), and remaining present and available yet non-intrusive, such as sitting nearby while you finish paperwork.

4. Information Gathering: Current Needs and Concerns

Determine the specific problems and needs of the patient. Individual responses may be flavored by their own psychological backdrop (such as depression or anxiety), history of similar incidents (a prior MVA or death in the family), or other unpredictable elements (they can’t stand the waiting room music). In some cases, the need for referral to a specialist may become obvious here, such as uncontrolled schizophrenia or major stressors in the setting of known PTSD and a history of self-harm; don’t try to “wing it” in complex psychiatric cases.

Follow their lead, and don’t press for details — a CISD-type debriefing can come later, if appropriate. Listen actively and openly. Look for expressions of emotion in their remarks, then make clarifying comments such as: “It sounds like you’re being really hard on yourself about what happened” or “It seems like you feel that you could have done more.” No matter what, don’t judge.

5. Practical Assistance

Assist the patient with any practical issues, which may be dominating (or over-dominating) their attention. Offer to notify friends or family, arrange for needed support, or obtain information about their care. Larger needs (such as questions about the costs of treatment) may be beyond your immediate power to address, but you can often take the first step, such as notifying hospital staff of their concerns. At the very least, provide whatever information you can and discuss a plan for resolving the problem. Even small measures like a warm blanket can have both practical and psychological benefit.

Remember that, although you may not be the most knowledgable or appropriate resource for many concerns, as an EMS provider you may be the only person who has the time and ability to address them. If you don’t make that phone call or find them a glass of water, it may be a long time until anybody else does; and it may not seem like a priority to find someone to move their car, but imagine how much better they’ll feel after it gets ticketed and towed.

6. Connection with Social Supports

Make an effort to enlist the patient’s support structure. In some cases, the first step may be to actually ask some version of, “Do you have a support network?” Some patients, such as the elderly or homeless, may not, and may need to rely particularly on institutional support, such as social workers.

When multiple individuals are in a group, such as family members at a scene or in the waiting room, ask if they have any questions or requests; this can provide a jumping-off point for further communication.

Make particular effort to bring children together with their parents or caregivers, and try not to separate them unnecessarily. Consider engaging children with simple activities, such as tic-tac-toe, “air hockey” (wad up paper and try to blow it across a table into the opposing person’s “goal”; this also promotes deep breathing), or the scribble game (one person scribbles on a paper, and the other tries to make it into something coherent).

7. Information on Coping

This step focuses on describing common stress reactions so that individuals will be more equipped to manage them. It is probably best left to more specialized professionals, since our own training is usually limited here.

8. Linkage with Collaborative Services

Help pass the patient along to existing resources, either by providing contact information or through direct referral. Most hospitals will have phone numbers or extensions for mental health, social work, counseling, and other services, and there are hotlines available for individuals not in care at a facility. (It’s worth having this sort of thing in your phone or on a cheat sheet, so that it’s available when you need it.)

When bringing in other aid, and even when making routine hand-offs to ED staff and the like, try to smooth the transition of care. Patients often feel as if they are passing through the hands of an endless series of personnel, with each one demanding to hear their story (and probably take their vital signs). Make an effort to give full, complete reports, and to establish your credibility through word and deed so that receiving staff feel less of a need to do it all over again; in particular, try to communicate whatever concerns or emotional state the patient is currently experiencing, so that the job of managing it can be seamlessly turned over. Introduce the new “helper” (for instance, the RN) directly to the patient, and let them know that they’ll be taking care of them; don’t just disappear, or they may feel abandoned.

Further information can be downloaded here from the National Center for PTSD.